Posts Tagged ‘Women in medicine’

For several years now, I’ve been the social media curmudgeon in medicine. In a 2011 New York Times op-ed titled “Don’t Quit This Day Job”, I argued that working part-time or leaving medicine goes against our obligation to patients and to the American taxpayers who subsidize graduate medical education to the tune of $15 billion per year.

But today, eight years after the passage of the Affordable Care Act, I’m more sympathetic to the physicians who are giving up on medicine by cutting back on their work hours or leaving the profession altogether. Experts cite all kinds of reasons for the malaise in American medicine:  burnout, user-unfriendly electronic health records, declining pay, loss of autonomy. I think the real root cause lies in our country’s worsening anti-intellectualism.

People emigrated to this country to escape oppression by the well-educated upper classes, and as a nation we never got past it. Many Americans have an ingrained distrust of “eggheads”. American anti-intellectualism propelled the victory of Dwight Eisenhower over Adlai Stevenson – twice – and probably helped elect Bill Clinton, George Bush, and Donald Trump.

Don’t make the mistake of thinking that American anti-intellectualism today is exclusive to religious fundamentalists and poorly educated people in rural areas. Look at the prevalence of unvaccinated children in some of America’s most affluent neighborhoods, correlating with the location of Whole Foods stores and pricey private schools. Their parents trust Internet search results over science and medical advice.

Remember when physicians were heroes?

For a long time, physicians were exempt from America’s anti-intellectual disdain because people respected their knowledge and superhuman work ethic. The public wanted doctors to be heroes and miracle workers. The years of education and impossibly long hours were part of the legend, and justified physician prestige and financial rewards. Popular TV series in the ‘60s and ‘70s lionized the dedication of Ben Casey, Marcus Welby, Dr. Kildare, and Hawkeye Pierce. In real life, heart surgeons Michael DeBakey, who performed the first coronary bypass operation in 1964, and Christiaan Barnard, who performed the first heart transplant in 1967, became famous worldwide.

But over the next decades, greater opportunities for women to enter medicine coincided with a decline in public respect for physicians. Though many women in medical school and residency worked just as hard as men — or harder — to prove themselves, the money and prestige didn’t follow. Women physicians working full-time today earn an average 28 percent less than men, a gender wage gap that persists across specialties.

Could it be that the anti-intellectual tradition in America tolerates highly educated men in the doctor’s role, but can’t quite stomach giving the same respect and pay to highly educated women? Nearly everyone has heard of the Apgar score for assessing the health of newborn babies, but how many people know that Virginia Apgar, who developed it in 1952, was a physician?

Less formality, less respect

Even as more women entered the medical profession, other social trends dimmed the public image of physician infallibility. The tragic Libby Zion case in 1984, in which exhausted residents made a series of errors resulting in the death of the 18-year-old college freshman, prompted the first-ever law to limit resident work hours.

While Depression-era parents raised the “baby-boomer” generation to work hard without questioning it, their grandchildren in Generation X demanded extended parental leave, shorter work days, and more vacation time. “Work-life balance” became their mantra. Workplaces everywhere became more informal and dress codes more casual.

Patients and hospital staff began to address physicians by their first names. (As a Baylor medical student, I would have loved to see the fallout if anyone in the operating room at Methodist Hospital had addressed Dr. DeBakey as “Mike”.) Younger physicians, especially women, went along with it so they wouldn’t seem elitist or unfriendly; they started answering their phones saying, “This is Emma,” instead of  “This is Dr. Smith.” It should come as no surprise that the line between physician and non-physician “care providers” began to blur.

The trap of “evidence-based medicine”

The concept of “evidence-based medicine” gained traction, mandating that every disease and procedure must be managed according to a standardized set of guidelines. Never mind that science evolves, and that early research findings often don’t pan out in large-scale studies. Forget that some published research proves to be fraudulent or tainted by conflict of interest. Ignore the fact that a protocol that works well for one disease may be exactly the wrong treatment for another, and that many patients have multiple diseases.

Individual physician judgment today is presumed wrong if it defies a standardized protocol. Compliance with checklists is viewed as proof of quality care. Ezekiel Emanuel, one of the architects of the Affordable Care Act, has even suggested that medical training be cut by 30 percent, as he believes healthcare by protocol makes all that book-learning unnecessary. In this view, all “providers” are interchangeable pawns.

Today, young physicians start their careers in a world where their advancement and pay may depend on patient satisfaction surveys, and the Internet fuels distrust of medical advice. They spend their days functioning as data-entry clerks, with more face-time in front of a computer than with patients. Innovation is stifled. Their clinical decisions are reviewed for compliance with protocols, and their hospitals are run by administrators for whom the delivery of healthcare quickly and cheaply is the main objective. They fear replacement by mid-level “providers” who can be trained to follow a protocol without question.

Today’s medical students and residents see the dissatisfaction all around them, and they note the growing number of physicians who want to change careers. Many look for pathways out of clinical care from the start of their training, obtaining additional degrees — in public health, information technology, bioengineering, or business administration — that can lead to creative careers outside medicine. Some young physicians turn away from clinical care to become entrepreneurs, designing smartphone apps or using mobile vans to deliver IV therapy for hangovers.

The dystopian future

American anti-intellectualism is growing worse. Our national inability to debate political issues with reason rather than emotion is a symptom of this disease. So is the distrust of higher education and of experts in every field including medicine. I wonder every day if we are being honest with college students about the future when we encourage them to apply to medical school.

The Association of American Medical Colleges predicts a shortage of up to 120,000 physicians in 2030, both in primary care and specialties. A third of currently practicing physicians will be older than 65 within ten years. They’ll be retiring soon, and too many young physicians already are looking for an exit strategy. Even if we train more physicians, if the malaise in American medicine doesn’t get better we won’t keep them in clinical practice.

Unless something changes, we may find ourselves in a dystopian future with only 10 physicians who spend all their time in Washington writing “evidence-based” protocols, while people without the education to realize the full implications of what they’re doing will decide at your bedside which protocol applies to you. Are you feeling lucky?

Avoiding #metoo in medicine

Let me say first that any woman who has ever been harassed or assaulted should NEVER be made to feel that it is her fault. It is always the perpetrator’s fault. Men can be boors, or worse, and testosterone can be toxic.

I went to Princeton University at a time when the ratio of men to women was 8:1, graduated from medical school in the 1980s, and raised two daughters. I’ve had ample reason and plenty of time to think about strategies to deal with harassment, parry a verbal thrust, and maneuver out of a potentially humiliating or harmful situation.

We’re lucky in medicine that we have intellectual qualifications — board scores, professional degrees — that are our primary entryway into medical school and residency programs. We’re not being judged PRIMARILY on our looks. Yet many social media comments recently have underscored the fact that some women in medicine have endured ridicule, harassment, and even assault in the course of their careers. It makes sense to explore any tactic that can help other women avoid similar painful encounters.

Here are some tips — learned through long experience. My hope is that they might help younger women in medicine feel less like potential victims, and more like strategists in a behavioral chess game.

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How reporter Jan Hoffman and the New York Times manage to insult female physicians and get their facts about anesthesia so wrong all at the same time.

My husband and I, both anesthesiologists, enjoy our Sunday mornings together — coffee, the New York Times, a leisurely breakfast. No rush to arrive in the operating room before many people are even awake.

Today, though, seeing reporter Jan Hoffman’s front-page article in the Times — “Staying Awake for Your Surgery?” — was enough to take the sparkle out of the sugar. Her article on how much better it is to be awake than asleep for surgery reminded me why I left a plum job as a reporter for The Wall Street Journal to go to medical school — because reporters have to do a quick, superficial job of covering complex issues. They aren’t experts, but seldom admit it.

Physician anesthesiologists across the country are likely to face patients on Monday morning who wonder if they ought to be awake for their surgery. The answer to that question may well be “no”. But according to Ms. Hoffman, that answer reflects “physician paternalism”, and makes us opponents of the “patient autonomy movement”, because a patient should have the right to choose to be awake.

It’s not that simple.

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Dr. Margaret Wood, who chairs the Department of Anesthesiology at Columbia University Medical Center, has published a wonderful article titled “Women in Medicine:  Then and Now“, in the journal Anesthesia and Analgesia.

I think I speak for many of us in admitting that Anesthesia and Analgesia doesn’t occupy a prominent place on my bedside table. Many readers may have missed Dr. Wood’s article. That’s a shame, because it isn’t just about anesthesiology, and speaks to issues in medicine independent of specialty or gender. Here are some of my favorite passages about lessons she learned over the course of her long and successful career:

“1. It is important to have a passion for what you do if you strive for excellence. If you have that passion, then the efforts do not feel like a sacrifice and “burnout” is not an issue. I cannot imagine that Virginia Apgar spent a single moment talking, thinking, or worrying about burnout.

2. The current fashion to complain about “life balance” can be self-destructive; however, pacing oneself is critical. You can have it all, just not all at once. The Chairman of Anatomy gave the inaugural lecture to my incoming class of medical students. His thesis was that as a physician/medical student you could have (i) an active time-consuming social life, (ii) a family, and (iii) a career, but to be successful you should have no more than two of these at the same time. I believe this to be true and have followed this advice since.

3. Women should be careful not to fall into the trap of feeling entitled to special considerations or engage in special pleadings. Our patients want their physician to be the best, whatever his or her sex. There is no room for a physician of either sex who is less qualified or less committed because of outside responsibilities.

4. Women no longer need to “prove themselves” against the sea of doubters who dominated medicine 40 years ago. Fortunately, we are now past that point and such doubts, are I hope, antediluvian. Women are where they are today, however, because many of us felt that demonstrating that women really could “do it” was a moral imperative and one to which we were fully committed.

5. Parents need to manage their work and family responsibilities to ensure that both receive their full attention. This will often mean ensuring that they have excellent childcare to allow them to have the confidence to focus on work when that is required. This may be expensive, but it is a critical investment by both parents in their family’s future. Successfully raising children is a joint responsibility of both partners; what is critical to women is also critical to men, and vice versa. Women starting out on this journey can be assured that it is possible to raise well-adjusted children in a home in which both partners have challenging and successful careers, provided there is a true partnership in the family.”

Is Dr. Wood a curmudgeon, or perhaps a dinosaur? That could be, but I find her honesty refreshing.

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Of cats and termites

How an eleven-pound cat precipitated domestic chaos and delayed surgery

Termites are endemic in southern California, and we’ve had spot treatments several times over the years at various sites in our house where little piles of sawdust have appeared as evidence of termite activity. Finally it became clear that the termites were winning and more aggressive treatment was in order: tenting. This is the process of hoisting a big, brightly-colored tent over the whole house and putting an end to the termites with a poisonous gas called Vikane, or sulfuryl fluoride.

Tenting is a major project. All food and medicine has to be put in special non-porous plastic bags, sealed tightly with tape. All the people, animals and plants have to be evacuated. Natural gas must be turned off. The house is sealed in the tent for 24 hours, then aired out with big industrial fans. On the third day, you can go home.

The fumigation was scheduled to begin on Monday. Over the weekend, we put the food and medicines in bags, or most of it anyway. I arranged for our three tabby cats to be boarded at the vet. Our dog-walker agreed to board Milo, our 100 lb. Rottweiler-mix dog, at her house. My husband Steve complained continuously, as though I had bought bags of termites and sprinkled them around the house on purpose to annoy him.

On Monday morning Steve and I both went to work, to our day jobs as anesthesiologists, and I came home at 11:30 to take the cats to the vet and hand off the dog. The exterminators were expected to arrive between 1:30 and 3:30 pm. I had the presence of mind to lock all three cats in the family room before I went to work. Now my task was to get all three into their carriers and off to the vet.

Going three rounds with Tigger

I decided to tackle Tigger, the five-year-old male, first. He is strong, sinewy and sleek, and we’ve nicknamed him the “stealth cat” because he is very good at eluding capture. I thought he would be the biggest challenge to put in the carrier, and I was right.

Round 1. I caught Tigger, shoved him into his carrier, and tried to hold him down while I zipped it up. He turned into a writhing yowling clawing dervish and fought his way out.

Round 2. I think he got out even faster that time.

Round 3. Met the definition of insanity, as I hoped for a different outcome from the same sequence of actions. Same cat, same outcome.

I considered my options, and decided to get Joe and Tabitha into their carriers and drive them to the vet. This, I thought, would give Tigger time to calm down. Joe is a placid 17-year-old senior cat, and while he doesn’t like to go anywhere, he can’t be bothered to put up much fuss. Tabitha is a 10-month old kitten. It took some doing to catch her, and she was very unhappy, but she was still too small to win the contest. I drove Joe and Tabitha to the vet and came back home. As I came in the house, I caught a brief glimpse of Tigger, still locked in the family room. I put some more food in bags and waited for Krys, the dog-walker, to arrive and help me with Tigger.

1 pm: Krys arrived. We discussed the plan to put Tigger in his carrier. Only problem: we couldn’t find Tigger. We looked all over the family room and kitchen. We searched in the coat closet, under furniture, and behind the washing machine and dryer. No Tigger. It was as if he had evaporated. Milo (the dog) at this point was becoming anxious, trotting around after me and panting, sensing a disturbance in the force. I decided it would be best to let Krys and Milo leave.

1:30 pm: A fair amount of stuff still needed to be put in bags, but I couldn’t find the cat anywhere. Rising anxiety. I called my husband. A veteran of married life, he recognized the tone of desperation in my voice, and promised to come home as soon as he could arrange coverage. Cat clearly more important (for the moment) than heart surgery.

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